DrVirgo
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A 44 year old woman is being operated on for acute appendicitis. After inguinal incision, a gangrenous, ruptured, retrocecal appendix is encountered. The cecum adjacent to the appendix is edematous and livid. A pus collection behind the ascending colon, spreading to the lower pole of the right kidney, is drained (100 mL of pus). Median laparotomy adn extensive lavage are done. Antibiotics active against anaerobes are added to the regimen. Which of the following is the most appropriate course of action?
A. Simple appendectomy
B. Appendectomy with ileostomy
C. Appendectomy with cecostomy
D. Resection of the cecum together with the appendix
E. Right hemicolectomy with ileotransverse anastamosis
(whats the differenct between choice C and D??)
Does anyone else think this is a hard question? I thought appendicitis was supposed to be an easy topic! 
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| robin082006
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E. Right hemicolectomy with ileotransverse anastamosis
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| DrVirgo
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Yes, thats right.
How did you come to that conclusion?
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| robin082006
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C. Appendectomy with cecostomy: "Ostomy" usually used for colon or rectal surgery, intestine is opened out abdomen
D. Resection of the cecum together with the appendix: this is resection of both mentioned part.
this patient has complication of appendicitis, causing inflamation of right colon-->hemicolectomy then we connect the left intestinal tract (anastomosis)
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| DrVirgo
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you are right... good explanation. 
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| Justice
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I think this is only a theory. In practice, no surgeon would proceed to forming the anastomosis when there is an active infection in the cavity. Iliostomy + Resection of the cecum together with the appendix is the first step until the infection is over, and then only (E)...
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| DrVirgo
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Justice wrote:
I think this is only a theory. In practice, no surgeon would proceed to forming the anastomosis when there is an active infection in the cavity. Iliostomy + Resection of the cecum together with the appendix is the first step until the infection is over, and then only (E)...
Thats what I thought as well...
However the explanation says: Experience has shown that right colectomy with ileotransverse anastamosis has best postoperative results, when resection of part of the ascending colon is required. In this patient removal of ascending colon will allow better debridement of the space behind it.
This was from UW... a hard question as only 16% of people got it right.
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| Justice
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The explanation skips one important point: this is not a one step surgery.
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| ashfaque
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ans B, appendicecomy and covering ileostomy is the safest approach, as ceacum is edematous not gangrenous so why to take it out, plus anostomosis in presence of gangrene sepsis and infection has higher chances of leakage leading to feacal fistula and peritontis(feacal peritonitis has a very high mortality rate)
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| coolmavs
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Yes. I also thought that this would NOT be a 1 step surgery. Since the caecum is edematous and not gangrenous, maybe we can do an appendicectomy now and do an ileostomy to give rest to the intstines further down and do observation with antibiotics. If things dont improve then maybe we will have to consider hemicolectomy. Pls do correct me if I am wrong, since I am no surgeon, but I do hope that I am thinking along the right track.
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